COVID-19 health information system assessments in eight European countries: identified gaps, best practices and recommendations

Abstract Background Global threats, such as the coronavirus disease 2019 (COVID-19) pandemic, have highlighted the critical importance of robust and well-functioning health information systems (HIS) in effectively addressing public health emergencies. To enhance the understanding and the functioning of such systems, it is crucial to perform HIS assessments. This article explores key gaps and identifies best practices in the COVID-19 HIS of eight European countries. Furthermore, it provides recommendations to strengthen European systems for better pandemic preparedness. Methods Assessments were carried out in eight European countries using an adapted version of the WHO support tool to strengthen HIS and the Joint Action on Health Information assessment tool. The assessments took place between January 2022 and April 2023. Results Four main themes emerged regarding the gaps and best practices identified in the various HIS: organizational, technical, legal and resources. The results of these assessments show different approaches implemented by countries to improve their HIS and respond to the demands of the pandemic. Conclusions It is imperative for countries to draw valuable insights from the COVID-19 pandemic and strengthen their HIS. This involves the adaptation or development of pandemic preparedness plans, strengthening legislative framework for data sharing and privacy protection, promotion of data standards and international definitions and implementation of a unique person identifier. Additionally, countries will have to act in this post-pandemic era and integrate the newly developed systems and innovations into existing structures, maintain and develop trust by citizens through transparent communication and engage in infodemic management and address resource gaps in the workforce.

(2) The coverage of cause-of-death information recorded on the death registration form is (close to) 100% (3) What is the quality of the cause-of-death information recorded on the death registration form related to COVID-19?
(3) Cause-of-death information recorded on the death registration form related to COVID-19 is of high quality: -medical doctors are trained (as part of the regular curriculum and/or postgraduate training) to fill in the death registration forms; -clear rules and a legal framework that define under which circumstances an autopsy needs to be performed to establishing the cause of death are in place; -the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) is used to code causes of death; -coding is performed by dedicated, specifically trained staff; -the proportion of all deaths coded to ill-defined causes is low -COVID-19 death certificates are regularly matched and updated

Data sources_4 Data sources_3
What is the status of health service records related to COVID-19?
(1) What kind of record-keeping systems are used in hospitals and in primary health care/by general practitioners?How are these records compiled and how is the information shared, with regards to COVID-19?
(1) A centralized electronic health record (EHR) system is in place.If various electronic information systems are used, interoperability between these systems is ensured also in regard to COVID-19.(2) Did your routine system that was already in place accomodate for the COVID-19 pandemic or did you have to implement a new system?
(2) The routine system of a centralized electronic health record functioned well and smoothly, also during the COVID-19 pandemic.
(3) Can data for secondary purposes -such as quality control, planning and policymaking -easily be extracted from these systems?
(3) Tailored aggregated datasets can be extracted easily by administrators, managers and health care staff.

Data sources
Supplementary table I: COVID-19 health information system assessment item list adapted from the item list of the WHO Support tool to strengthen health information systems (4) What is the coverage and quality of information on medical procedures registered in the health service records?(4) There is high coverage of registration of care provided -including diagnostic tests, treatments (surgery, drugs, other), medical devices, type of care (inpatient, ambulatory, emergency) and length of stay -in the health service records, and appropriate international classifications are used (such as International Classification of Health Interventions).Biases affecting these data are limited and known.
(5) What is the coverage and quality of information on COVID-19 diagnoses registered in the health service records?
(5) Coverage of COVID-19 diagnoses registered in the health service records is high.For hospital discharge records ICD-10 is used to register diagnoses, and in primary health care International Classification of Primary Care is used.Biases affecting these data are limited and known.

Data sources_5 Data sources_6
Which (preventive) health programmes are implemented?
(1) What is the coverage and quality of COVID-19 testing?
(1) There is a central, national database with programme-based data on all COVID-19 testing.
(2) How is the coverage and quality of information from the COVID-19 vaccination programme?
(2) There is a central, national database with programme-based data on all vaccinations in the vaccination programme, with full coverage.
(3) There is a central, national database with programme-based data on all adverse effects, including COVID-19 vaccinations.

Data sources_6 Data sources_7
Are regular health surveys conducted?
(1) Are regular health surveys/ online panels carried out in the framework of COVID-19?
(1) A (long-term) operational plan is in place, including financing from the public budget, for (regular) conducting of national health surveys.The methodology applied in these surveys is in accordance with international standards and, if applicable, international data delivery requirements.Specific efforts are made to make sure that hard-to-reach groups are adequately represented in the sample (e.g.people in long-term care facilities, non-native speakers, homeless people) also in relation to COVID-19.
(2) Do health and statistical authorities work together on survey design, implementation and data analysis and use?
(2) Cooperation mechanisms exist (e.g. between the public health institute, statistics office and universities).

Data sources_7 Data sources_8
What data sources on health care resources exist?
(1) What data sources exist on human resources?
(1) A national human resources database tracks the number of health professionals by major professional category working in either the public or the private sector, with complete coverage.A national database tracks the annual numbers graduating from all health training institutions, with complete coverage.Each individual health care provider in the national human resources database has been assigned a unique identifier code, which stays with them for their practising career; this permits data on the same provider to be merged.
(2) What data sources exist on facilities to address the crisis to e.g. the number of hospital beds.
(2) A national database of public and private sector health facilities is in place, with complete coverage.Each health facility has been assigned a unique identifier code that permits data on facilities to be merged.

Data infrastructure_1 Data infrastructure_1
What is the status of adoption of EHR and other electronic information systems in the national HIS?
(1) Are EHR systems being used by health care facilities/providers? (1) Health care facilities and providers only use electronic patient records; there is no parallel paper record keeping.
(2) Is an electronic system for registration of deaths in place?
(2) An electronic system for registration of deaths is in place.
(3) Is an electronic system in place for notification and registration of COVID-19?
(3) An electronic notification system for COVID-19 is in place, with real-time data, allowing authorities to respond immediately.(4) Were these electronic information systems adapted to address COVID-19?Describe the technical changes that were implemented to deal with the crisis.
(4) In case the system in place had to be adapted, such changes are clearly documented.
(5) Can COVID-19 patients access their own data in the EHR system?(5) Patients can access their own data, empowering them by allowing them to check these for completeness and correctness.

Data infrastructure_2 Data infrastructure_3
Are any interoperability standards in relation to COVID-19 defined and used?
(1) Are any commonly agreed interoperability requirements or standards in place for the information systems in the HIS and wider information systems on COVID-19?
(1) The standards that health care providers and facilities need to use to communicate between organizations and to report to authorities are defined.
(2) Are any accreditation standards in place for digital services and applications that focus on ensuring interoperability with other services and applications?
(3) Which organizations or bodies are responsible for development of health sector and broader national standards?(4) Which organizations or bodies are responsible for undertaking conformance, compliance and accreditation of products and services -including ICT -used in the health sector?
(2-4) Specific offices/agencies are in charge of defining official interoperability standards, compliance with these standards and accreditation of products and services.
(5) What is the level of adoption of interoperability standards among existing health services and applications?
(5) An overview of the level of adoption of health care standards is available (for example, through a survey); the level of (planned) adoption is high.(6) Did this level change during the crisis or was the level of adoption changed due to the crisis?(6) The level of adoption of interoperability standards was adaquate to accomodate information flows during the crisis.

Data infrastructure_3
Data infrastructure_4 Is a unique personal identification number (UPIN) in use?
(1) Is a UPIN issued at birth for each citizen?
(1) A UPIN is issued at birth for each citizen, and this is used across government services, including health services.

Data management_1
Data management_1 What metadata standards are in use?
(1) Are common standards in use?
(2) Are these standards aligned with international standards?
(1-2) Common standards are used for metadata for official (health) statistics, which are aligned with international metadata standards.
(3) COVID-19 Metadata are structurally available for all official statistics and can be easily located and accessed by users of these statistics.(4) If adjustments such as standardization or weighing are used, how are these selected?
(4) In-country adjustments use transparent, well established methods.If a weighing factor is applied, methods and variables used are clearly described.

Data management_2
Data management_2 What quality control mechanisms are applied for the data sources listed above?
(1) What kind of automated and or/manual control mechanisms are built into the EHR/information systems for COVID-19 ?
(1) Automated logic checks are built into the systems/ Regular manual checks are performed according to well established and well documented protocols to check for completeness and correctness of the COVID-19 data.
(2) Are audits performed to check the completeness and correctness of COVID-19 data?
(2) Regular audits are performed -e.g. by the health insurance company or ministry of health -to check the quality of the diagnosis-related group information submitted by health care facilities.

Data management_3 Data management_3
How can COVID-19 data sources be accessed and used for secondary purposes?
(1) Are publicly funded data sources publicly available and published as open data?
(1) Publicly funded data sources are publicly available and published as open data (provided that the necessary data protection safeguards have been taken into account).
(2) An electronic data exchange platform for the safe and efficient exchange between (semi-)governmental organizations is in place.All government departments and other relevant agencies are connected to the platform.
(3) Is a central COVID-19 data warehouse in place?
(3) An integrated COVID-19 data warehouse is operated at the national level, containing data from all data sources (both population-based and facility-based sources, including all key health programmes).The data warehouse has a user-friendly user interface, which is accessible to various user audiences and which allows for the tailored extraction of data and indicators.
(4) Are opportunities available to link COVID-19 data sources safely at the subject level and perform comprehensive analyses -for example, through a closed controlled working environment operated by the statistical office, or through anonymization and linkage by a trusted third party.
(4) Opportunities are available to link COVID-19 data sources safely at the subject level and perform comprehensive analyses -for example, through a closed controlled working environment operated by the statistical office, or through anonymization and linkage by a trusted third party.

Data management_4 Data management_4
Are COVID-19 international data delivery requests being met? (1) Are COVID-19 data collection methods and analytical approaches (e.g.calculation of indicators) in line with international standards and recommendations?
(1) COVID-19 data collection methods are in line with international standards and recommendations.
(2) Is the country able to meet all COVID-19 data delivery requirements from the international organizations of which it is a member/with which it is collaborating?
(2) The country can fulfil all COVID-19 health information requests from international organizations.
(3) How much strain is that putting on COVID-19 health system of the country?
(3) The courntry can fulfil all COVID-19 health information requests from international organizations, this is not putting any strain on the health system.
(4) Does the country participate in international health information projects or activities regarding COVID-19?
(4) Which actors are involved in COVID-19 international projects or activities is known.
Developments with regard to health information at an international level are routinely monitored and shared by experts in the HIS.

Resources for data collection_1
Resources for data collection_1 Is an adequate legal framework in place for HIS data collections for COVID-19?
(1) Is there a legal basis for the COVID-19 data collections?
(1) There is a clear legal basis for the most important COVID-19 data collections.
(2) Which data elements are defined in the law?
(3) Is an adequate legal framework in place for linking and sharing the COVID-19 data collections?
(3) Criteria for data privacy, secondary processing, sharing of information and data linkage are specified.A legal framework that is not too restrictive is in place -i.e. one that strikes the right balance between data protection and making health data available for the public good.Accessibility of essential data sources for the most important HIS stakeholders (statistical office, ministry of health) is regulated by law.
(4) Are requirements for COVID-19 data storage defined in the law?(4) Requirements for COVID-19 data storage are clealry defined in the law.(5) Have legal aspects limited the country in the COVID-19 data collection?
(5) The legal basis that was in place did not limit data collections for COVID-19.

Resources for data collection_2
Resources for data collection_2 Are sufficient human resources available for maintaining and operating COVID-19 data collections?
(1) Do HIS stakeholders have adequate tools to maintain and operate COVID-19 data collections?
(1) HIS stakeholders have adequate tools (e.g.database and data management software) to maintain and operate COVID-19 data collections.
(2) Do HIS stakeholders have adequate manpower to maintain and operate COVID-19 data collections?
(2) HIS stakeholders have adequate manpower, and staff turnover is limited.
(3) Do HIS stakeholders have adequate capacity to maintain and operate COVID-19 data collections?
(3) HIS stakeholders have adequate capacity -i.e.staff with the right technical skills and expertise.Regular training is provided/funds are available for regular training.

Resources
Item ID

Analysis_1 InfDisSurv_5
How is analysis of COVID-19 surveillance data performed?
(1) Which stakeholders are involved in the design and implementation of COVID-19 surveillance strategies and data analysis?
(1) Health and statistical authorities work together on the design and implementation of COVID-19 surveillance strategies and data analysis.Cooperation mechanisms exist between the public health institute, statistics office, universities and others.
Examples are provided.
(2) What tools are in use for analysis of COVID-19 data?Please provide examples.
(2) Examples are given of electronic platforms that integrate, synthesize and visualize information pertaining to COVID-19 surveillance.Computer-generated customized reports, tables, charts, maps and metadata are implemented.
(3) Are COVID-19 data collection methods and analytical approaches (e.g.calculation of indicators) in line with international standards and recommendations?Please provide examples.
(3) COVID-19 data collection methods are in line with international standards and recommendations, and the country fulfils all health information requests from international organizations.
(4) Is analysis of COVID-19 data conducted routinely by person and cause/risk factor/mode of transmission?Please describe specific data outputs.
(4) Data analysis is performed by person (e.g.age, sex, race), biological characteristics (e.g.immune status), acquired characteristics (e.g.marital status), activities (e.g.occupation, leisure activities, use of medications/tobacco/drugs) or the conditions in which they live (e.g.socioeconomic status, access to medical care), according to documented SOPs.Standardized rates of disease are calculated by person.Tables and graphs, along with interpretations, are produced.Examples are provided.
(5) Is analysis of COVID-19 surveillance data routinely conducted by place?Please describe specific data outputs.
(5) Occurrence of COVID-19 is described by relevant geographical location (i.e.place of diagnosis or report, birthplace, site of employment, school district, hospital unit or recent travel destinations) according to documented SOPs.Tables and maps, along with interpretations, are produced.Examples are provided.

Analysis_2 Analysis_1
Is a core set of health indicators defined for COVID-19 and its wider effects?
(1) COVID-19 core indicators were transparently identified for national and subnational levels.Selection of indicators is also informed by international indicator sets.
(2) Indicators cover all categories of health indicators, such as determinants of health; health system inputs, outputs and outcomes (health systems performance assessment); health status; and health inequalities.If possible, the set includes relevant indicators from other policy sectors (e.g.social affairs, education).

Indicators
(3) How are the indicators defined and calculated?
(3) Indicator definitions exist and the method for their calculation is documented.If applicable, the numerator and denominator of the indicators are clearly defined.
(4) Are metadata available and harmonized within the country and across countries?
(4) Regularly updated metadata exist for each indicator and are publicly available.Metadata include the categories definition, calculation/method, available dimensions/subgroups (e.g.age, gender, geographical information, nationality, migration, social status -e.g.education, employment status, income), rationale and data sources.

Analysis_3 Analysis_2
What kind of analyses are performed on the core indicators in the framework of COVID-19 and its wider effects?
(1) Core indicators can be broken down according to relevant subnational entities (e.g.regions, municipalities).Subnational disaggregations are produced regularly.
(2) Definitions of national core indicators are aligned with international definitions to allow international comparisons; these are produced regularly.If different definitions and/or data sources are used for national indicator values and for international comparisons, the reasons for this are clearly explained in the indicator metadata.
(3) Periodic population projections are made.These are used to make demographic projections for key indicators.If adequate trend data are available, combined demographic and epidemiological projections are made for key indicators.
(4) Are comparisons between subgroups made/are analyses of health inequalities performed?
(4) Data for the core indicators can be disaggregated according to age, sex, socioeconomic status and other relevant stratifiers (e.g.ethnicity).Disaggregated indicator values are produced regularly.
(1) How and how often are they reported/published/updated?
(1) Core indicators are regularly reported in standardized tables, in health reports and in basic tools for spatial comparisons and comparisons over time.
(2) What is the frequency at which data for the core indicators become available?
(2) The datasets used to calculate the core indicators are updated regularly, and the frequency of these updates is in line with policy needs.(3) Are regular publication dates/periods available for each indicator?
(3) A publication schedule is available.

Analysis_5 Analysis_6
Is the country investing in Big Data and Artificial Intelligence (AI) research and development related to COVID-19?
(1) Is a Big Data/AI strategy related to (public) health for COVID-19 related issues in place?
(1) A strategy for Big Data/AI, either standalone or as part of the digital health/eHealth strategy or another national digital health initiative, is in place.
(2) Is action on Big Data/AI included in the national budget?
(2) The national health and/or research budget includes dedicated funds for action on Big Data/AI.

Big Data and Artificial Intelligence (AI)
(3) Has the Big Data/AI strategy changed to address the COVID-19 crisis?
(3) Innovative mechanisms were set up to address issues such as contact tracing, vaccine registrtaion, apps etc. (4) Are ethical Big Data/AI requirements, standards and best practices listed and respected?(4) A set of ethical principles is defined, together with policies and regulations.Best practices are actively shared.
(5) Are infrastructure requirements for Big Data/AI and data science defined?
(5) The following infrastructure requirements are clearly defined: computing capacity, storage capacity, networking infrastructure, security policies.( 6) Is the country working on transforming the health information workforce to be fit for the new Big Data/AI era? ( 6) The country has a plan to train health information professionals in data science and Big Data/AI, including adequate funding.

Analysis_6 Analysis_7
Do HIS stakeholders have adequate resources to analyse and report on COVID-19 indicators regularly?
(1) Do HIS stakeholders have adequate tools for regular analysis and publication of COVID-19 indicators?
(1) HIS stakeholders have adequate tools for analysis (e.g.computers, servers, analysis software) and publication (e.g.module for interactive dashboard).
(2) Do HIS stakeholders have adequate manpower for regular analysis and publication of COVID-19 indicators?
(2) HIS stakeholders have adequate manpower, and staff turnover is limited.
(3) Do HIS stakeholders have adequate capacity for regular analysis and publication of COVID-19 indicators?
(3) HIS stakeholders have adequate capacity -i.e.staff with the right skills and expertise (such as statisticians, epidemiologists, geographical information system (GIS) experts, data visualization experts, communication experts).A multidisciplinary team works on publication of the core indicators.Regular training is provided/funds are available for regular training on analysis skills.

Item ID_WHO Question Probing question Expectations
Health reporting_1 Health reporting_1 Is there capacity for reporting and publication of COVID-19 health reports and surveillance information?
(1) Are such health reports being produced on a regular basis, and by whom?A health report can either be a more traditional report in paper/PDF format, or a web-based report/website.
(1) Regular surveillance reports are produced by the national public health agency or comparable institutions, independent of the ministry of health.Scientific standards and common transparency requirements are followed in the production of the reports.
(2) Is information from the COVID-19 surveillance system available for population health monitoring?
(2) Information from COVID-19 surveillance is readily available for use in population health reports, where it can be placed in a broader context.
(3) How comprehensive are these reports?
(3) Epidemiological reports are written in easy-to-read language, use a combination of texts and informative visualizations and include key messages, analysis outputs, interpretation of results and options for actions (i.e.assessment of preventive measures).
(4) Foresight and scenario exercises are performed to inform long-term strategic health policy-making.
(5) What format do the health reports use?
(5) Regular health reports use standard reporting formats and tools, preferably publicly available web-based reports that use interactive visualization tools that allow generation of tables, graphs/charts, maps and infographics or COVID-19 dashboards.It is possible to download the visualizations and the data on which they are based.Tailored summaries/factsheets are available for different target audiences.
(6) Are these reports publicly available?(6) Health reports or surveillance reports are publicly available and readily accessible.
(7) What kind of communication and dissemination strategies are used for these reports?Are infodemic management tools used?
(7) Comprehensive communication and dissemination strategies for COVID-19 are in place, including mass media, social media, online health (information) platforms, newsletters, email messages, presentations and lectures.Active after-care is also part of the communication and dissemination strategy, including follow-up on social media.Experts talking to the mass media have received relevant training.

Health reporting_2 Health reporting_2
What mechanisms exist for using COVID-19 health and surveillance reports in the policymaking process?
(1) What is the mechanism for using COVID-19 health and surveillance reports in the health policy-making process?
(1) There is a formal, public and transparent procedure for using COVID-19 health and surveillance reports in the policy-making process.Parliament is informed by the ministry of health when formal health reports are published.
(2) Are the COVID-19 health and surveillance reports used to inform intersectoral policy-making, and do other policy sectors also include information on health in their reporting efforts/use health information for informing their policies (a Health in all policies approach)?
(2) An intersectoral governmental body that discusses (how to use) the COVID-19 health and surveillance reports is in place, and its decisions are formally and publicly reported.Health is a standard dimension in reports of other policy sectors.
(3) Is it known to what extent policy-makers and other users (such as media, patient organizations, NGOs, professional organizations) actually use the reports?
(3) User surveys are conducted regularly.Website statistics are monitored and analysed regularly.Reports about the results of the user surveys and website statistics are publicly available.

Health reporting_3 Health reporting_3
Are COVID-19 health reports produced at the health care facility and provider levels?
(1) Do managers and medical staff use health reports to monitor and improve performance (e.g.quality control, patient safety)?
(1) Managers and medical staff regularly use health reports to monitor and improve performance.Such reports are discussed jointly (e.g. at the department or team level) and ways to improve are decided together.
There is an open attitude among health care staff towards measuring and monitoring performance.Health care staff feel safe to discuss (suboptimal) quality of care and performance.
(2) What kind of indicators are used for these reports?
(2) Indicators that are acknowledged by (international) peers as valid and useful are used.Indicators used include patient-reported outcomes (PROMs) and patient-reported experiences (PREMs).

Health reporting_4 Health reporting_4
Do HIS stakeholders have adequate resources for producing and publishing regular COVID-19 health reports?
(1) Do HIS stakeholders have access to adequate tools for health reporting?
(1) HIS stakeholders have access to adequate tools for producing health reports (e.g.quality criteria/toolkit, evidence resources) and publishing health reports (e.g.software for creating interactive graphs and options for integrating videos in online reports).
(2) Do HIS stakeholders have adequate manpower for producing and publishing regular health reports?
(2) HIS stakeholders have adequate manpower, and staff turnover is limited.

Resources
(3) Do HIS stakeholders have adequate capacity for producing and publishing regular health reports?
( (1) Are information products regularly demanded by users like senior managers and policy-makers?
(1) The regular information and knowledge products produced within the HIS and their publication schedules are well known by policy-makers, senior managers and other actors such as media representatives.Senior managers and policy-makers demand complete, timely, accurate, relevant and validated HIS information, and know how to interpret and use it.
(2) Are support mechanisms available to train relevant actors on how to interpret and use the products?
(2) Training or information courses on the products and their use are offered regularly.
(3) Does the COVID-19 information produced within the HIS meet the needs of the policy-makers?
(3) Regular exchange sessions take place to identify the information needs and to assess the timeliness and usefulness of the formats with policymakers and other relevant users.The outcomes of these sessions and implemented changes are documented and reported.Exchange and integrated knowledge translation approaches are applied to make sure that information and knowledge produced meet the needs of policy-makers.
(4) What kind of communication mechanisms are in place if there are questions or ad hoc requests for this type of information?
(4) A rapid response team/mechanism is in place to respond quickly to ad hoc questions (e.g. when the ministry of health is looking for health information to answer questions from parliament).After-care is a structural element in the communication and dissemination plans for health information and knowledge products.
A regularly conducted user survey is applied to identify the usability of health information and knowledge products.

Knowledge translation_3
What kind of knowledge translation tools and mechanisms are used?
(1) Are specific tools to stimulate uptake of information and knowledge in policy-making used?
(1) Producers of reports use tools specifically aimed at stimulating uptake of information and knowledge in policy-making, such as policy briefs and policy dialogues.
(2) Alongside the more traditional push and pull mechanisms, are exchange and integrated approaches also applied for knowledge translation?
(2) Exchange and integrated approaches for knowledge translation are applied.In exchange approaches, information analysts and relevant users of the HIS work in partnership, often facilitated by knowledge brokers, to collect the necessary evidence.In integrated approaches, a knowledge translation infrastructure is institutionalized and represents clear objectives for action, regular assessments of the relevance of its efforts and incorporation of elements of push, pull or exchange efforts.
(3) To what extent are the applied knowledge translation tools and mechanisms institutionalized?
(3) The applied knowledge translation tools and mechanisms are institutionalized: they a structural element of the health policy-making process.

Knowledge translation_4
Do HIS stakeholders have adequate resources for COVID-19 knowledge translation?
(1) Do HIS stakeholders have adequate manpower for knowledge translation?
(1) HIS stakeholders have adequate manpower for knowledge translation.

Resources
(2) Do HIS stakeholders have adequate capacity for knowledge translation?
(2) HIS stakeholders have adequate capacity.Staff have been trained in knowledge translation concepts, tools and skills, and adequate budget id available for training to keep staff capacity up to date.
(3) Was the distribution of resources for knowledge translation changed during the COVID-19 pandemic?
(3) The distribution of resources was adaquate.
3) HIS stakeholders have adequate capacity, i.e. staff with the right skills and expertise (such as statisticians, epidemiologists, GIS experts, data visualization experts, writers/editors, communication experts).A multidisciplinary team works on producing the health reports.Regular training is provided/funds are available for regular training on reporting skills.